1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 4 Major Jonathan Letterman: Unsung war hero and father of modern battlefield medicine AUTHORS Jonathan T. Liebig, MD Laurier J. Tremblay, MD, FACS Peter W. Soballe, MD, FACS Romeo C Ignacio, MD, FACS Department of General Surgery, Naval Medical Center San Diego, San Diego, CA CORRESPONDING AUTHOR Romeo Ignacio, MD, FACS 34800 Bob Wilson Dr. San Diego, CA 92134 619-532-9659 [email protected] ©2016 by the American College of Surgeons. All rights reserved. CC2016 Poster Competition • Major Jonathan Letterman • 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Hippocrates said, “War is the only proper Education and early career school for surgeons.” Dr. Jonathan Letterman Major Jonathan Letterman (1824–1872) grew up in Canonsburg, (1824-1872), as the medical director of PA, the son of a prominent western Pennsylvania surgeon the Army of the Potomac, originated the (Figure 1). He graduated from Jefferson College (now Washington and Jefferson College) in 1845, and then attended Ambulance Corps that trained men to quickly Jefferson Medical College in Philadelphia. On graduation in transfer the wounded to field dressing 1849, he applied for and received an army commission. For stations. He later organized a system to the next 13 years, he was assigned throughout North America where he cared for sick and injured soldiers, challenged by triage and transfer to evacuate patients to terrain, exposure, malnutrition, and infectious disease in remote three levels of care, an innovation that saved locations. In California when the Civil War began, he returned thousands of lives in future conflicts. His east at the end of 1861.1 accomplishments remain an integral part of Care of the wounded at the onset of the U.S. military medical operations that affect Civil War the lives of countless wounded warriors today. Letterman deserves the title of “the Technological advances in Civil War weaponry had far outpaced battlefield tactics. The newly developed 0.58 caliber Springfield father of modern battlefield medicine.” musket was accurate to more than 500 yards, but armies still lined up across fields in traditional formations and charged each other head-on. More than a third of a unit could die in such assaults. Overcrowding and abysmal hygiene in camps caused thousands more to suffer dysentery, scurvy, typhoid fever, pneumonia, smallpox, tuberculosis, measles, and malaria. About 60 percent of the Union soldier deaths during the Civil War were from noninjury diseases.1,2 The first salvo of the war revealed a startling lack of organization, planning, and effectiveness in the care of so many sick and injured. At the Battle of Bull Run (or Manassas), clearing the wounded from the battlefield took a week. The wounded had to make their way to Washington to seek medical care, including one man shot in both thighs and the scrotum. One civilian organization assisting the military after Bull Run reported, “[It] was unable to learn of a single wounded man having reached the capital in an ambulance.” Ambulances devoted to the transport of the wounded were rare. Wagons from the quartermaster corps were devoted for hauling munitions, then appropriated for transporting patients only on the rare occasions when they were free. Injured soldiers had to be carried off the battlefield by friends and other soldiers. Not surprisingly, many chose not to return.2 The army failed to bring medical care to the wounded in any location. Army brass scrimped its appropriations for medical care, a budgetary decision based on limited resources, political challenges and lack of insight. Line officers prioritized troop movements and the delivery of weapons and ammunition at the expense of medical supplies and support.2 There were few military surgeons with adequate training and expertise. In 1860, the US Army had only 100 doctors 1 for 16,000 soldiers, a ratio that became only worse when the ©2016 by the American College of Surgeons. All rights reserved. CC2016 Poster Competition • Major Jonathan Letterman • 22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Union Army reached its peak strength of 2 million, at which Letterman’s solutions point it had 10,000 surgeons. Most were civilian physicians with a limited contract with the government. Their training In May 1862 Letterman was appointed first as medical director was at best a two-year stint at an unregulated, proprietary of the Department of West Virginia where he established a medical school. Few had formal training in surgery, and solid reputation and won the admiration of political influential fewer had ever treated a gunshot wound. Without a separate figures in the Army and government. The dismal state of command structure for the medical department, there was care of wounded became quickly evident, so he was named no oversight or evaluation of qualifications. Promotions were medical director for the Army of the Potomac, the largest army often based on seniority and political connections instead in the Union.1 In less than two years he developed many of of clinical performance. Surgeons from one regiment often the ideas and plans that continue to serve as the foundation refused to care for soldiers of another.1,2 for battlefield medicine today. Recognizing his leadership and medical skill, General George B. McClellan, commanding Wounded soldiers removed from the battlefield found general of the Army of the Potomac, gave Letterman authority themselves in a hodgepodge of locations, few that could to make any changes necessary to improve and maintain generously be called a medical facility. Often they were places the health of his fighting force. The latter faced a myriad of of opportunity such as homes and barns Resources were challenges with ingenuity, dedication and foresight.2 few and of poor quality, without established supply lines, command, and hierarchy of supervision. An established civilian From his years of service prior to the Civil War he knew his first hospital in a city that happened to be close to an action was task was the health and nutrition of the soldiers. If more were overwhelmed by massive numbers of casualties. Resources fit, there would be more for battle. Camp hygiene practices were quickly exhausted making necessary secondary dispersal were improved, especially handling of waste. Soldiers were of the wounded to more distant cities and towns. Without given bigger and more nutritious rations, prepared with better stabilization and initial treatment, patients often succumbed cooking methods and more hygienic handling of food. Breakfast during the long journeys to community facilities or died shortly was ensured. Improved shelter allowed better sleeping after their arrival.2 conditions. Breaks for rest were mandated. Improved supplies included clean uniforms. Morale improved. After less than a month under Letterman as its chief medical officer, the disease rate in Army of the Potomac decreased by one-third.1,2 ? ©2016 by the American College of Surgeons. All rights reserved. CC2016 Poster Competition • Major Jonathan Letterman • 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Letterman’s next undertaking was improved casualty could be saved, and which had fatal injuries. Ambulances at evacuation. At Letterman’s request McClellan issued an order collection points transported the wounded to field hospitals in that created an ambulance corps with an established structure nearby buildings, and those with more severe injuries to general for its management, regulation, and evaluation. Each ambulance hospitals. His system provided consistent and better medical was staffed by a driver and two men, each trained for specific care to the wounded. It also kept soldiers with mild injuries tasks and with no combat duties. Letterman and three others closer to the battlefield where they could return to battle once designed the original ambulances, in service for most of the they recovered.2 war. Called the “Wheeling Wagons,” each was pulled by two The Battle of Fredericksburg in December 11-15, 1862, tested horses, carried two to six patients, and had compartments for Letterman’s newly restructured medical corps, just months water, stretchers, and medical supplies. The use of ambulances after his appointment in May (Figure 2). The corps was ready to shuttle line officers about was expressly prohibited.2 with 1,000 ambulances and 550 medical officers, one in fifteen Two major battles in the span of just a few weeks in the of whom performed operations. The Union Army suffered summer of 1862 illustrated the consequences of Letterman’s nearly 13,000 casualties. Surgeon George Stevens of the Sixth ambulance corps. On August 28, 1862, the Battle of Second Corps wrote of the experience, “The medical department has Manassas left 14,000 northern troops were killed or wounded. become so thoroughly systematized, that wounded and sick The wounded lay on the battlefield, desperate for help, for a men were cared for better than they had ever been in any army full week before all of them could be removed from amongst before…[This] was perfected…by the efficient and earnest the dead.2 Less than a month later on September 17, 1862, the medical director of the army, Dr. Letterman; to whom belongs Battle of Antietam had more than 12,000 Union casualties. the honor of bringing about this most desirable change.”2 In stark contrast to the battle less than a month earlier at Manassas, every injured Union soldier was evacuated from the Legacy battlefield in just 24 hours. Letterman wrote, “[It] affords me much gratification to state that so few instances of apparently Letterman’s innovative changes in the delivery of battlefield unnecessary suffering were found to exist after that action and medical care were widely adopted and established through that the wounded were removed from that sanguinary field in an Act of Congress in 1864.